Background: Diagnostic delays remain a leading cause of preventable harm in hospitalized patients. Existing tools for analyzing diagnostic delays offer comprehensive guidance, however their complexity and time demands limit wider adoption. Institutional event review, peer review, and educational processes therefore often fail to elucidate upstream root causes of diagnostic delays and instead erroneously treat diagnostic delays themselves as causal.
Purpose: Quality and safety leaders, educators, frontline hospitalists, and trainees all stand to benefit from a framework that facilitates directed, consistent, and timely case reviews for diagnostic delays. A team with expertise in quality improvement, event review, diagnostic excellence, and medical education has created a streamlined two-stage framework called CLeAR-Dx (Clinical Learning through Analysis and Reflection for Diagnostic Excellence).
Description: The CLeAR-Dx framework facilitates the systematic identification and analysis of diagnostic delays in the inpatient setting, empowering hospitalists to:- Identify diagnostic inflection points — critical moments when earlier recognition might have changed the clinical trajectory; – Analyze diagnostic uncertainty, including how complexity, ambiguity, or competing hypotheses impacted clinical reasoning; and- Appreciate the multifactorial nature of diagnostic delays, encompassing cognitive, interpersonal, and systems-level contributors.Step 1 is a two-question screening tool to rapidly assess whether a diagnostic delay occurred and whether it contributed to patient harm. Step 2 is a guided causal analysis to aid in localizing opportunities in various steps of the diagnostic process and to examine contributing factors across cognitive, team-based, and systems domains.Structured feedback on clarity, relevance, and feasibility was solicited from clinicians and diagnostic safety experts at our four institutions, whose input informed iterative revisions. Based on this feedback, the CLeAR-Dx framework is practical for use in safety event review and in quality and safety educational processes. Additional formal validation testing is underway.
Conclusions: The CLeAR-Dx framework can be practically integrated into local quality, safety, and educational efforts. We are currently engaged in further validation of this framework including cognitive interviewing and comparative testing with existing tools to assess reviewer satisfaction, effectiveness, and time required.